Health Alerts

Action: The Snohomish Health District Health Officer Dr. Gary Goldbaum sends alerts via email to local health care providers. Alerts cover current local, regional or national health threats and important updates on medical care and protocols. Alerts are written as needed to cover urgent or emergent health issues.

See my Health Alert of July 15 for background on the closure of these clinics and resources to help clinicians manage patients. Although Apple Health (Medicaid) is no longer contracting with SPC, prescriptions written by providers of SPC who have not had action taken on their licenses will continue to be paid by Apple Health’s managed care organizations and fee-for-service program for at least 30 days. Local providers are reporting that specialty pain clinics have no further capacity and are not accepting referrals. Rather than referring patients to someone else for their pain medication refill, please provide their pain management care.

Recommendations

Many of these patients have been on high doses of opioids for years and are likely physiologically dependent. Slow taper (rather than abrupt cessation) is likely to be the most successful strategy to wean them off of the opioids, which will lead to withdrawal.

Some patients may have developed a substance use disorder. For those patients on high doses of opioids (>90 MED) or on combination therapy with other central nervous system depressants, consider prescribing naloxone for family or friends to administer if the patient overdoses.

Some patients may also be on long-term benzodiazepines. The Washington State Agency Medical Directors’ Group (AMDG) recommends tapering of high-dose opioids before addressing benzodiazepines use: “Unlike benzodiazepine withdrawal, opioid withdrawal symptoms are rarely medically serious, although they may be extremely unpleasant.”

Check the Prescription Monitoring Program to screen for prescriptions from other providers.

For patients with a substance use disorder, refer to an addiction medicine specialist or the Washington Recovery Help Line at 1-866-789-1511 or via the web at http://www.warecoveryhelpline.org. Note that many specialists may not be able to accept immediate referrals.

Refer for case management or care coordination through the patient’s managed care plan.

Providers may have concerns about violating the Washington pain rules when accepting the care of patients on more than 120 MEDs. Although consultation with a pain specialist is best, the authors of Washington’s pain rules recognized this may not always be an option. As such, the rules outline components of appropriate chronic pain management:

Clear documentation.

Adherence to guidelines. The Washington AMDG and/or the CDC guidelines are recognized appropriate standards of care.

Appropriate safeguards.

The pain rules also allow for telemedicine consultation. The University of Washington TelePain program is a free service that supports primary care providers in the management of patients who are complex or on high-dose opioids. Information about this program can be found at http://depts.washington.edu/anesth/care/pain/telepain/index.shtml.

Actions requested: Advise patients who may be or have been exposed to Zika virus that Zika virus can be transmitted sexually from an infected man or woman to an uninfected partner.

Background

See prior Health Alerts for background on and recommendations about Zika virus. Because our understanding of Zika virus is evolving, recommendations of the Centers for Disease Control and Prevention (CDC) are changing frequently. Studies had previously confirmed that Zika virus was sexually transmitted from men to women. Recent evidence suggests that Zika virus is also sexually transmitted from women to men. Still uncertain is the interval during which an infected woman can transmit the virus sexually and if women can transmit the virus to other women through sexual contact.

Recommendations

For now, CDC recommends:

Given the risk of microcephaly or other neurologic conditions when a fetus is exposed to Zika virus, pregnant women with sex partners (male or female) who live in or who have traveled to an area with active Zika virus transmission should consistently and correctly use barriers against infection during sex or abstain from sex for the duration of the pregnancy.

Couples who are not pregnant and are not planning to become pregnant and in which a partner had confirmed Zika virus infection or clinical illness consistent with Zika virus disease should consider using barrier methods against infection consistently and correctly or abstain from sex as follows:
― Men with Zika virus infection for at least 6 months after onset of illness
― Women with Zika virus infection for at least 8 weeks after onset of illness

Couples in areas without active Zika transmission in which one partner traveled to or resides in an area with active Zika virus transmission but did not develop symptoms of Zika virus disease should consider using barrier methods against infection or abstaining from sex for at least 8 weeks after that partner departed the Zika-affected area.

Couples who reside in an area with active Zika virus transmission should consider using barrier methods against infection or abstaining from sex while active transmission persists.

In response to CDC recommendations, the Washington State Department of Health has changed its testing guidance, as follows:

Symptomatic persons reporting unprotected sex with a partner who traveled to an area with Zika can be tested by RT-PCR, regardless of the partner’s gender or symptom history.

Symptomatic pregnant women with serum specimens collected <2 weeks after onset may be tested by RT-PCR (extending the testing period by 1 week).

Asymptomatic pregnant women with possible exposure to Zika should be offered RT-PCR testing on serum and urine if <2 weeks after last possible exposure. If RT-PCR tests are negative, a second serum specimen should be collected 2-12 weeks after exposure for serologic testing.

If fetal abnormalities are identified on ultrasound, serum and urine should be tested by RT-PCR in addition to testing of amniotic fluid.

If a sample is submitted to the state laboratory for which RT-PCR test has not already been done and that tests positive for IgM, the state laboratory will do confirmatory RT-PCR.

For a live birth with evidence of maternal or fetal Zika virus infection, infant serum should be collected in addition to cord blood.

Contact the Health District at 425-339-5278 if you have questions about Zika virus testing and to arrange for confirmatory testing.

Twenty-one confirmed and 3 probable cases of AFM have been reported to CDC from January 1 through June 30, 2016 among persons 6 months to 64 years of age. Dates of onset for confirmed cases ranged from December 1, 2015 through June 18, 2016; ten (48%) had onset of limb weakness after May 1, 2016. Cerebrospinal fluid (CSF) specimens available from 86% (18/21) of confirmed cases were tested at CDC; all specimens were negative for enterovirus at CDC. Pleocytosis was present in seventeen (81%) of confirmed AFM cases with a median of 50 cells/mm3 (range, 6-758/mm3). One of the probable cases is a Washington resident; two confirmed cases were residents of other states, but hospitalized in Seattle.

Report confirmed or suspected cases of AFM promptly to the Health District at 425-339-5278. We will provide guidance on laboratory testing of specimens for enteroviruses, West Nile virus, and other infectious etiologies known to be associated with AFM. When reporting, please complete the patient summary form found at http://www.cdc.gov/acute-flaccid-myelitis/hcp/data.html and fax to 425-339-8706.

Fluoroquinolones

Actions requested: Be aware that fluoroquinolones should not be used in patients with certain bacterial infections.

Background & Recommendations

The U.S. Food and Drug Administration (FDA) has changed the safety labeling for fluoroquinolones to enhance warnings about their association with disabling and potentially permanent side effects and to limit their use in patients with less serious bacterial infections. Because the risk of these serious side effects generally outweighs the benefits for patients with acute bacterial sinusitis, acute exacerbation of chronic bronchitis, and uncomplicated urinary tract infections, the FDA has determined that fluoroquinolones should be reserved for use in patients with these conditions who have no alternative treatment options. For some serious bacterial infections, including anthrax, plague, and bacterial pneumonia among others, the benefits of fluoroquinolones may outweigh the risks and it is appropriate for fluoroquinolones to remain available as a therapeutic option. See the complete FDA release at http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm513183.htm